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Form 1046 is used by the local intellectual and developmental disability authority (LIDDA) Diversion coordinator to request an adult nursing facility (NF) transition slot for Home and Community-based Services (HCS).
When to Prepare
Form 1046 is completed by the LIDDA Diversion coordinator to request an adult NF transition slot for HCS once a person residing in an NF has expressed a desire to transition to the community from the NF.
LIDDA staff must scan the completed form, along with any supporting documentation, and send by secure email to HHSC at LIDDARequests@hhsc.state.tx.us. The subject line should read “Request for HCS Adult NF Transition Slot.”
Date of Request — Enter the date the request is being submitted to HHSC.
LIDDA Name — Enter the name of the LIDDA requesting the adult NF transition slot for HCS.
Comp Code — Enter the requesting LIDDA’s designated component code.
LIDDA Diversion Coordinator — Enter the name of the Diversion coordinator submitting the request.
LIDDA Diversion Coordinator Email Address — Enter the email address of the LIDDA Diversion coordinator.
Area Code and Telephone No. — Enter the area code and telephone number for the LIDDA Diversion coordinator.
Person’s Name — Enter the first and last name of the person for whom the request is being made.
CARE ID — Enter the person’s Client Assignment and Registration (CARE) identification number.
Name of Legally Authorized Representative — Enter the first and last name of the legally authorized representative, if applicable. If not applicable, check the Not Applicable box.
Date of Nursing Facility (NF) Admission — Enter the date the person was admitted to the NF.
Medicaid Number — Enter the person’s Medicaid number for whom the request is being made.
Date of Birth — Enter the person’s date of birth.
Date of PASRR Evaluation (PE) — Enter the person’s date of the Preadmission Screening and Resident Review (PASRR) Evaluation.
By submitting this form to HHSC, the LIDDA attests that the request is for a person who meets the following criteria:
- The person is at least 21 years of age;
- The person currently resides in an NF;
- The person has expressed a desire to live in a community setting; and
- It is not within the first 30 days after the person’s admission, if the person was admitted to the NF for rehabilitative purposes.
Comments — Enter any relevant information. This is not a required field, but helpful in communicating with HHSC.
Diversion Coordinator Signature and Date — The Diversion coordinator signs the form and enters the date. The last section is for HHSC use only.
Date and time request is received — HHSC staff enters the date and time.
Reviewer Signature and Date — The reviewer signs the form and enters the date.